Sharon, Kent nursing homes fined over medication errors, injuries

Seven nursing homes, including two in Northwestern Connecticut, have been fined by the state Department of Public Health in connection with medication errors and incidents that led residents to be burned or break a leg.

The homes are in Kent, Sharon, North Branford, Westport, Greenwich, Danielson and New Britain.

• Sharon Health Care Center, in citations July 24, was fined $1,580 and $1,050 in connection with several violations of state regulations.

On Oct. 30, 2013, a resident was burned on the leg by a hot pack during a ride to a doctor’s office. The director of rehabilitation told state officials that in retrospect, it showed poor judgment for the rehab department to give the resident a hot pack for the half-hour ride, DPH records show. The home also lacked documentation to show it had checked the temperature of the heating unit, DPH found.

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In another incident, a nurse noted April 14 that a resident was in excruciating pain, but had not been given pain medication the night before, records show.

The home reported that a nurse had been retrained in response to the incident, but that he or she later resigned and left Connecticut, records show.

Another resident slept in urine after no aide answered the call bell seeking help April 23, and in another incident, a registered nurse forgot to give the same resident pain medicine, records show.

The state also found that a resident with diabetes was not given prescribed medication May 12-19 because the medication required an authorization from the facility to be reordered. The resident’s doctor also was not told that the medication had not been given, DPH found.

In the case of a resident who lost 8 pounds in 15 days, medical personnel were not notified of the significant weight loss and that it was not entered into a computer system that was being checked nightly by a dietitian, DPH found.

On June 25, a licensed practical nurse admitted giving one resident the medications of another resident while being distracted, records show. The resident was hospitalized for nausea, and the nurse was fired, DPH records show.

The home’s administrator could not be reached for comment.

• In Kent, The Kent home was fined $1,960 on July 8 in connection with four residents who developed pressure sores. The home’s records did not reflect that interventions were done to prevent pressure sores, DPH records show.

A spokesman for the home could not be reached for comment.

• In North Branford, Evergreen Woods on July 8 was fined $1,020 in connection with a resident who sustained a broken leg, records show.

In September 2013, two aides stood the resident up instead of using a lift, records show. Two days later, an X-ray showed that the resident’s leg was broken, the DPH found. The two aides were disciplined, and the home’s staff was retrained in response to the incident.

Facility administrator Jaclyn Martinelli said the home investigated and reported the incident as soon as the woman complained of pain, and took swift action in regard to the certified nursing assistants.

“Our initial and ongoing training for CNAs is extensive,” she said. “In this case, we provided additional training to the CNAs involved to ensure they have a thorough understanding of the safe transfer of residents.”

• In Danielson, Regency Heights was fined $1,090 on July 1 in connection with an incident in which a resident with diabetes was given 10 times the amount of insulin that had been prescribed by a doctor, DPH records show.

The resident was hospitalized after receiving the wrong dose four times Dec. 2 and Dec. 3, 2013, records show.

A registered nurse said when she looked at the physician’s order, she thought it said 40 units, instead of four, so she transcribed it in the medical administration record as 40, DPH records show. The director of nursing said the nurse should have asked another nurse about the dosage or called the doctor.

The home’s administrator could not be reached for comment.

• In Greenwich, Fairview Healthcare Center on June 12 was fined $570 in connection with a resident who was discharged to a relative on May 25 in error, DPH records show.

A conservator for the resident had asked the home to monitor the visits of a relative, who had a history of substance abuse and misuse of the resident’s money, records show. The resident was discharged to the relative after the relative showed a power of attorney form. When the conservator was notified about the discharge a day later, 911 was called and the resident was found at a local motel and was returned to Fairview.

It was determined that the relative was found to have presented an invalid power of attorney, and an official at the home admitted she should have notified someone before letting the person go home with the relative, records show. Officials at Fairview could not be reached for comment.

•In New Britain, Walnut Hill Care Center was fined on May 7 by DPH $500 in connection with three incidents of medication errors. On Dec. 27, 2013, one resident was given the wrong medication and was hospitalized for lethargy, records show.

On Jan. 24, the home failed to give a resident pain medication, and Feb. 21, another resident was given the wrong dosage of Ativan, with no ill effects, records show. In response, the home retrained three licensed practical nurses on how to dispense medication, records show.

The home’s new administrator, Janet Shahen, declined to comment.

• Westport Health Care Center on July 2 was fined $570 in connection with incidents involving residents who were smoking. In one incident, a resident had been ordered to wear an apron when smoking, but the home’s smokers’ log failed to reflect the use of the apron, records show. In another case, records failed to reflect that another resident had been educated about the home’s smoking policy, according to DPH.

Westport Health Care could not be reached for comment.

This story was reported under a partnership with the Connecticut Health I-Team (www.c-hit.org).